Fourth and fifth carpometacarpal fracture and dislocation of the hand: new classification and treatment

Hamatometacarpal fracture-dislocation: A case report

Hamatometacarpal fracture-dislocation is a rare condition. Only a few cases have been reported in the literature. We present the case of a 26-year-old male patient who sustained a coronal fracture of the body of the hamate with the fifth metacarpal base interposed between volar and dorsal fragments on his right dominant hand. The patient underwent open reduction and internal fixation of the hamate with a 2.0-mm cortical screw and stabilization of the dislocated fifth metacarpal with Kirschner wire. At six months follow-up, total range of movement was allowed, the patient experienced no pain, and had successfully returned to work.

Threaded intramedullary headless nail fixation for fractures requiring carpometacarpal stabilization

Carpometacarpal (CMC) fracture-dislocations are uncommon hand injuries, with few studies available regarding their treatment. The current operative treatment options include fixation with K-wires, mini-screws, or plates, though there is no standardized approach because of varying injury patterns and complications associated with each device. The INnate™ threaded intramedullary nail is a relatively novel treatment option that has shown promise in metacarpal fracture fixation by facilitating faster mobilization and recovery with enhanced rotational stability and no compression to prevent fracture displacement and shortening. This study assesses the efficacy of the INnate™ nail for fixation of CMC fracture-dislocations of the second through fifth joints. Nine patients with fourteen CMC fracture-dislocations treated with the INnate™ nail at the University Medical Center between 2019 and 2021 were enrolled in the study. We evaluated postoperative outcomes in terms of pain, total active range of motion (TAM), and return to normal activities. Of the nine patients, seven returned for follow-up. The average time to radiographic union was 11.5 weeks. At final follow-up, no patient reported pain (n = 6). Four patients had 100% TAM, 1 had 95% TAM, and 1 had 25% TAM. The average percentage of normal activity resumed was 84.0% (n = 5). No significant complications were reported. One patient had a dorsal spanning plate; hence, we were unable to record outcomes measures regarding the CMC injury. An additional patient had diminished ROM of the injured hand, but his last follow-up was only 1 month postop. Our pilot data overall suggest that the INnate™ threaded intramedullary nail has the potential to improve treatment algorithms for CMC fracture-dislocations.

Ulnar-sided carpometacarpal fractures and fractures-dislocations. A systematic review and publication guidelines

BACKGROUND

Intra-articular fractures and fracture-dislocations of the ulnar-sided carpometacarpal joints (US-CMC) are common and under-reported. Their diagnosis is often delayed or incomplete, and there is no consensus as to the best treatment. The aim of this systematic literature review was to focus on the quality of existing data and to describe in detail the available evidence on the diagnosis and treatment of these lesions. Based on our findings, we will propose guidelines for improving the design of future studies on these lesions.

METHODS

This systematic literature review looked at all articles published between 1918 and 2019 on US-CMC fractures and fracture-dislocations. The quality of the articles was evaluated using the Quality Appraisal Tool devised by Moga et al. Information on the diagnostic and therapeutic methods were extracted along with epidemiological data, classifications, and clinical and radiological outcomes.

RESULTS

Of the 500 articles identified, 13 were included. According to the Quality Appraisal Tool, three of these articles had acceptable quality. While either radiographs or CT scans were used for the diagnosis, the radiographs were insufficient to precisely describe the lesions and guide the treatment. Conservative treatment or percutaneous surgical treatment was preferred for acute stable lesions without extensive fractures or comminution, while open surgical treatment was used most often in cases of unstable or sub-acute fractures and fracture-dislocations.

DISCUSSION

The current literature on this topic is made up of case series with a low level of evidence. CT is needed to assess and classify these lesions and select between conservative and surgical treatment. Unstable cases or those with delayed presentation should be treated with an open surgical approach. Based on our findings, we propose reporting guidelines for future studies on the treatment of US-CMC fractures and fracture-dislocations.

LEVEL OF EVIDENCE

III.

Intra-articular fractures of the hand

Fractures of the hand are common injuries and in particular, fractures involving the articular surfaces can present difficulties to the orthopedic surgeon in practice. Although the treatment of these fractures needs to be individualized based on fracture pattern and location, the goals for these fractures are to restore the alignment, stability, and congruity and to allow for early motion to prevent stiffness and traumatic arthritis. This article classifies the various types of intra-articular hand fractures as well as the workup and management of these injuries.

The safest direction of percutaneous pinning for achieving firm fixing of the fifth carpometacarpal joint

INTRODUCTION

Traditional treatment of unstable fifth carpometacarpal joint injuries is closed reduction and pinning. The purpose of this study was to determine the safest corridor for pinning of the fifth carpometacarpal joint to prevent iatrogenic injury to the ulnar nerve and tendons.

MATERIALS AND METHODS

In the first phase of study, three fresh cadavers were dissected and the safest directions of Kirschner wire (k-wire) insertion in the coronal and sagittal planes were determined for k-wire entrance 2 cm distal to the base of the fifth metacarpal. The second phase objective was to evaluate the accuracy of data obtained in the previous phase. Therefore, with five other cadavers, k-wires were inserted in a combination of maximum angles in different planes determined previously. The ulnar nerve branches and tendons were then investigate to detect possible damage. In the third phase, four fresh carpometacarpal joints were fixed with directions outside the range of the defined angles.

RESULTS

The safe direction determined in the first phase was a 20°-30° coronal plane angle relative to the body of the fifth metacarpal bone and between 10° volar to dorsal to 20° dorsal to volar angle in the sagittal plane. Insertion of k-wires in the second phase could fix the fifth carpometacarpal joint firmly without penetration of the volar and dorsal cortices of the hamate. All inserted k-wires outside the defined range resulted in injuries to nerves or tendons or loose fixing.

CONCLUSION

The safest corridor for pinning unstable fifth carpometacarpal injuries is 2 cm distal to the joint at an angle of 20°-30° to the coronal plane from 10° volar to dorsal to 20° dorsal to volar direction in the sagittal plane.